Patient referrals are on the rise in the US, but even with the advent of EHRs, steps are missed as clinicians and staff deal with an array of challenges. With support from CRICO/Risk Management Foundation of the Harvard Medical Institutions, IHI/NPSF convened an expert panel that identified nine steps in a closed-loop referral process. This report provides specific guidelines to help standardize the ways in which primary care practitioners activate referrals to specialists and then keep track of the information over time. Read more and download the report.

With support from the Gordon and Betty Moore Foundation, IHI/NPSF contracted with Westat to evaluate research on patient safety in the home and identify gaps. This report examines safety issues in the home, including challenges, funding mechanisms to support safe home care, and conceptual frameworks that seek to structure these disparate issues. It concludes with opportunities for research to advance the science of patient safety improvement in the home. Read more and download the report.

A resource toolkit from the IHI/NPSF Patient Safety Coalition to guide collaboration among health professionals and financial leaders to demonstrate the value and return on investment for safer, quality care.

With a grant from AIG, the National Patient Safety Foundation convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work. Read more and download their report.

RCA2 is a trademark of the National Patient Safety Foundation. NPSF does not endorse any software or training for the RCA2 process that is not directly provided by NPSF.

With a grant from The Doctors Company Foundation, NPSF convened a panel
of subject matter experts and stakeholders to examine best practices
around root cause analysis (RCA) and develop guidelines to help health
professionals standardize the process and improve the way they
investigate medical errors, adverse events, and near misses. Read more and download the report.

Reports & White Papers

This document summarizes projects completed with funding from the NPSF Research Grants program. Over the past decade, the projects have covered a broad range of topics in patient safety. This report provides citations for related subsequent research as well as the original projects.

This document set the strategy for the National Patient Safety Foundation’s research agenda by asking broad questions, such as “What is patient safety?” and “What goals can be achieved through research?"

In 1997, the National Patient Safety Foundation commissioned Louis Harris & Associates to conduct a survey of the experiences and opinions of adults about patient safety issues. Between July 30 and August 21, 1997, 1,513 telephone interviews were completed.

Patient and aviation safety experts and health policy leaders from around the country convened in March 2000 for a discussion on the recommendations of the IOM report, To Err Is Human. The roundtable was cosponsored by the Kaiser Permanente Institute for Health Policy, the National Quality Forum, and the Peter F. Drucker Archive and Institute.

Infusion Pumps with “Drug Libraries” at The Point of Care – A Solution for Safer Drug Delivery.

Ellen Kinnealey, BSN, received the NPSF Solutions Award for this study, which examined the use of an electronic drug library, which was clinician designed, hospital sanctioned, and customizable to different settings.